Evidence-based Treatment of Acute Lateral Ankle Sprain

Byung-Ki Cho

doi:10.14193/jkfas.2018.22.4.135

Journal List > J Korean Foot Ankle Soc > v.22(4) > 1130309

Go to TopGo to Top Go to BottomGo to Bottom

TOOLS

Cho: Evidence-based Treatment of Acute Lateral Ankle Sprain

Review Article

J Korean Foot Ankle Soc 2018;22(4):135-144.

Published online: 19 January 2018

DOI: https://doi.org/10.14193/jkfas.2018.22.4.135

Evidence-based Treatment of Acute Lateral Ankle Sprain

Byung-Ki Cho

Department of Orthopedic Surgery, Chungbuk National University College of Medicine, Cheongju, Korea

Corresponding Author: Byung-Ki Cho Department of Orthopedic Surgery, Chungbuk National University Hospital, 776 1sunhwan-ro, Seowon-gu, Cheongju 28644, Korea Tel: 82-43-269-6077, Fax: 82-43-274-8719, E-mail: titanick25@naver.com ORCID: https://orcid.org/0000-0001-7746-598X

Received 18 September 201826 October 2018 Accepted 6 November 2018

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Acute lateral ankle sprain, which is the most common musculoskeletal injury, can be treated effectively with appropriate evidence-based initial care using PRICE (protection, rest, ice, compression, and elevation) and functional rehabilitation. Many systemic reviews reporting a high-level of evidence supporting the clinical usefulness and necessity of primary surgical repair for acute lateral ankle sprain have been insufficient. Regardless of the severity of ligament complex injuries, the surgical treatment for acute lateral ankle sprain without concomitant pathologies is not recommended and should be considered only in young professional athletes with complete ligament rupture (grade III) and severe instability.

Keywords: Ankle, Sprain, Treatment, Evidence-based

REFERENCES

1.DiGiovanni CW., Brodsky A. Current concepts: lateral ankle instability. Foot Ankle Int. 2006. 27:854–66.

2.Waterman BR., Owens BD., Davey S., Zacchilli MA., Belmont PJ Jr. The epidemiology of ankle sprains in the United States. J Bone Joint Surg Am. 2010. 92:2279–84.

3.Kerkhoffs GM., Handoll HH., de Bie R., Rowe BH., Struijs PA. Surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults. Cochrane Database Syst Rev. 2007. 2:CD000380.

4.van den Bekerom MP., Kerkhoffs GM., McCollum GA., Calder JD., van Dijk CN. Management of acute lateral ankle ligament injury in the athlete. Knee Surg Sports Traumatol Arthrosc. 2013. 21:1390–5.

6.Hubbard TJ. Ligament laxity following inversion injury with and without chronic ankle instability. Foot Ankle Int. 2008. 29:305–11.

7.Kim HJ. Conservative management of ankle sprains. J Korean Orthop Assoc. 2014. 49:7–12.

8.O’Neill PJ., Parks BG., Walsh R., Simmons LM., Miller SD. Excursion and strain of the superficial peroneal nerve during inversion ankle sprain. J Bone Joint Surg Am. 2007. 89:979–86.

9.Coughlin MJ., Saltzman CL., Anderson RB., Mann RA. Mann’s surgery of the foot and ankle. 9th ed.Philadelphia: Elsevier;2014.

10.Jacobson JA. Musculoskeletal sonography and MR imaging. A role for both imaging methods. Radiol Clin North Am. 1999. 37:713–35.

11.Cho JH., Lee DH., Song HK., Bang JY., Lee KT., Park YU. Value of stress ultrasound for the diagnosis of chronic ankle instability compared to manual anterior drawer test, stress radiography, magnetic resonance imaging, and arthroscopy. Knee Surg Sports Traumatol Arthrosc. 2016. 24:1022–8.

12.Balduini FC., Tetzlaff J. Historical perspectives on injuries of the ligaments of the ankle. Clin Sports Med. 1982. 1:3–12.

13.Dias LS. The lateral ankle sprain: an experimental study. J Trauma. 1979. 19:266–9.

14.Jackson DW., Ashley RL., Powell JW. Ankle sprains in young athletes. Relation of severity and disability. Clin Orthop Relat Res. 1974. 101:201–15.

15.Clanton TO., Schon LC. Athletic injuries to the soft tissues of the foot and ankle. Coughlin MJ, Mann RA, editors. editors.Surgery of the foot and ankle. 7th ed.St. Louis: Mosby;1999. p. 1114–203.

16.Chan KW., Ding BC., Mroczek KJ. Acute and chronic lateral ankle instability in the athlete. Bull NYU Hosp Jt Dis. 2011. 69:17–26.

17.Kerkhoffs GM., Rowe BH., Assendelft WJ., Kelly KD., Struijs PA., van Dijk CN. Immobilisation for acute ankle sprain. A systematic review. Arch Orthop Trauma Surg. 2001. 121:462–71.

18.Smith RW., Reischl S. The influence of dorsiflexion in the treatment of severe ankle sprains: an anatomical study. Foot Ankle. 1988. 9:28–33.

19.Polzer H., Kanz KG., Prall WC., Haasters F., Ockert B., Mutschler W, et al. Diagnosis and treatment of acute ankle injuries: development of an evidence-based algorithm. Orthop Rev (Pavia). 2012. 4:e5.

20.Mehallo CJ., Drezner JA., Bytomski JR. Practical management: nonsteroidal antiinflammatory drug (NSAID) use in athletic injuries. Clin J Sport Med. 2006. 16:170–4.

21.van den Bekerom MP., Sjer A., Somford MP., Bulstra GH., Struijs PAA., Kerkhoffs GMMJ. Non-steroidal anti-inflammatory drugs (NSAIDs) for treating acute ankle sprains in adults: benefits outweigh adverse events. Knee Surg Sports Traumatol Arthrosc. 2015. 23:2390–9.

22.Petersen W., Rembitzki IV., Koppenburg AG., Ellerman A., Li-ebau C., Bruggemann GP, et al. Treatment of acute ankle ligament injuries: a systematic review. Arch Orthop Trauma Surg. 2013. 133:1129–41.

23.Kerkhoffs GM., van den Bekerom M., Elders LA., van Beek PA., Hullegie WA., Bloemers GM, et al. Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline. Br J Sports Med. 2012. 46:854–60. or surgical approach? EFORT Open Rev. 2016;1: 34-44. 25. Seah R, Mani-Babu S. Managing ankle sprains in primary care: what is best practice? A systematic review of the last 10 years of evidence. Br Med Bull. 2011;97: 105-35.

26.Kerkhoffs GM., Rowe BH., Assendelft WJ., Kelly K., Struijs PA., van Dijk CN. Immobilisation and functional treatment for acute lateral ankle ligament injuries in adults. Cochrane Database Syst Rev. 2002. 3:CD003762.

27.Kerkhoffs GM., Struijs PA., Marti RK., Assendelft WJ., Blankevoort L., van Dijk CN. Different functional treatment strategies for acute lateral ankle ligament injuries in adults. Cochrane Database Syst Rev. 2002. 3:CD002938.

28.Kemler E., van de Port I., Backx F., van Dijk CN. A systematic review on the treatment of acute ankle sprain: brace versus other functional treatment types. Sports Med. 2011. 41:185–97.

29.Feger MA., Glaviano NR., Donovan L., Hart JM., Saliba SA., Park JS, et al. Current trends in the management of lateral ankle sprain in the United States. Clin J Sport Med. 2017. 27:145–52.

30.Jones MH., Amendola AS. Acute treatment of inversion ankle sprains: immobilization versus functional treatment. Clin Orthop Relat Res. 2007. 455:169–72.

31.Hubbard TJ., Aronson SL., Denegar CR. Does cryotherapy hasten return to participation? A systematic review. J Athl Train. 2004. 39:88–94.

32.Bleakley CM., McDonough SM., MacAuley DC., Bjordal J. Cryotherapy for acute ankle sprains: a randomised controlled study of two different icing protocols. Br J Sports Med. 2006. 40:700–5. discussion 705.

33.van den Bekerom MP., Struijs PA., Blankevoort L., Welling L., van Dijk CN., Kerkhoffs GM. What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults? J Athl Train. 2012. 47:435–43.

34.Hubbard TJ., Denegar CR. Does cryotherapy improve outcomes with soft tissue injury? J Athl Train. 2004. 39:278–9.

35.Bleakley C., McDonough S., MacAuley D. The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. Am J Sports Med. 2004. 32:251–61.

36.Boyce SH., Quigley MA., Campbell S. Management of ankle sprains: a randomised controlled trial of the treatment of inversion injuries using an elastic support bandage or an Aircast ankle brace. Br J Sports Med. 2005. 39:91–6.

37.Beynnon BD., Renström PA., Haugh L., Uh BS., Barker H. A prospective, randomized clinical investigation of the treatment of first-time ankle sprains. Am J Sports Med. 2006. 34:1401–12.

38.Gwak HC., Seo SS., Kim CW. Nonoperative management of foot and ankle injury related to sports. J Korean Orthop Sports Med. 2004. 3:118–27.

39.Tully MA., Bleakley CM., O’Connor SR., McDonough SM. Functional management of ankle sprains: what volume and intensity of walking is undertaken in the first week postinjury. Br J Sports Med. 2012. 46:877–82.

40.Specchiulli F., Cofano RE. A comparison of surgical and conservative treatment in ankle ligament tears. Orthopedics. 2001. 24:686–8.

41.van den Bekerom MP., van der Windt DA., Ter Riet G., van der Heijden GJ., Bouter LM. Therapeutic ultrasound for acute ankle sprains. Cochrane Database Syst Rev. 2011. 6:CD001250.

42.Bennett M., Best TM., Babul S., Taunton J., Lepawsky M. Hyperbaric oxygen therapy for delayed onset muscle soreness and closed soft tissue injury. Cochrane Database Syst Rev. 2005. 4:CD004713.

43.Kannus P., Renström P. Treatment for acute tears of the lateral ligaments of the ankle. Operation, cast, or early controlled mobilization. J Bone Joint Surg Am. 1991. 73:305–12.

44.Pihlajamäki H., Hietaniemi K., Paavola M., Visuri T., Mattila VM. Surgical versus functional treatment for acute ruptures of the lateral ligament complex of the ankle in young men: a randomized controlled trial. J Bone Joint Surg Am. 2010. 92:2367–74.

45.Pijnenburg AC., Bogaard K., Krips R., Marti RK., Bossuyt PM., van Dijk CN. Operative and functional treatment of rupture of the lateral ligament of the ankle. A randomised, prospective trial. J Bone Joint Surg Br. 2003. 85:525–30.

46.Pijnenburg AC., van Dijk CN., Bossuyt PM., Marti RK. Treatment of ruptures of the lateral ankle ligaments: a meta-analysis. J Bone Joint Surg Am. 2000. 82:761–73.

47.Povacz P., Unger SF., Miller WK., Tockner R., Resch H. A randomized, prospective study of operative and non-operative treatment of injuries of the fibular collateral ligaments of the ankle. J Bone Joint Surg Am. 1998. 80:345–51.

48.Takao M., Miyamoto W., Matsui K., Sasahara J., Matsushita T. Functional treatment after surgical repair for acute lateral ligament disruption of the ankle in athletes. Am J Sports Med. 2012. 40:447–51.

49.White WJ., McCollum GA., Calder JD. Return to sport following acute lateral ligament repair of the ankle in professional athletes. Knee Surg Sports Traumatol Arthrosc. 2016. 24:1124–9.

50.Chaudhry H., Simunovic N., Petrisor B. Cochrane in CORR ^®: surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults (review). Clin Orthop Relat Res. 2015. 473:17–22.

51.Kobayashi T., Gamada K. Lateral ankle sprain and chronic ankle instability: a critical review. Foot Ankle Spec. 2014. 7:298–326.

52.Frey C., Feder KS., Sleight J. Prophylactic ankle brace use in high school volleyball players: a prospective study. Foot Ankle Int. 2010. 31:296–300.

53.Bahr R., Bahr IA. Incidence of acute volleyball injuries: a prospective cohort study of injury mechanisms and risk factors. Scand J Med Sci Sports. 1997. 7:166–71.

54.Milgrom C., Shlamkovitch N., Finestone A., Eldad A., Laor A., Danon YL, et al. Risk factors for lateral ankle sprains: a prospective study among military recruits. Foot Ankle. 1991. 12:26–30.

55.Verhagen EA., van Mechelen W., de Vente W. The effect of preventive measures on the incidence of ankle sprains. Clin J Sport Med. 2000. 10:291–6.

56.Handoll HH., Rowe BH., Quinn KM., de Bie R. Interventions for preventing ankle ligament injuries. Cochrane Database Syst Rev. 2001. 3:CD000018.

57.McKeon PO., Hertel J. Systematic review of postural control and lateral ankle instability, part II: is balance training clinically effective? J Athl Train. 2008. 43:305–15.

Figure 1.

Photograph of passive range of motion exercise using a band.

Figure 2.

Photographs of isometric peroneal strengthening exercise using a ball (A) and Achilles strengthening exercise against a wall (B).

Figure 3.

(A, B) Photographs of isotonic peroneal strengthening exercise using a band.

Figure 4.

Photograph of single leg balance exercise.

Table 1.

Clinical Classification of Lateral Ankle Ligaments Injury¹⁴)

Grade	Injured ligament	Clinical symptoms	Stress test
I	ATFL stretched	Mild swelling and tenderness	Anterior drawer test (―)
		Minimal difficulty with ROM and weightbearing	Varus tilt test (―)
II	ATFL torn and/or CFL tear	Moderate swelling and ecchymosis	Anterior drawer test (+)
		Anterolateral ankle tenderness	Varus tilt test (―)
		Restricted ROM, increasing difficulty to bear weight
III	ATFL, CFL torn and/or PTFL tear	Diffuse swelling and ecchymosis	Anterior drawer test (+)
		Tenderness over anterolateral capsule, ATFL, CFL	Varus tilt test (+)
		Inability to bear weight

Data from the article of Jackson et al. (Clin Orthop Relat Res. 1974;101:201-15).¹⁴) ATFL: anterior talofibular ligament, CFL: calcaneofibular ligament, PTFL: posterior talofibular ligament, ROM: range of motion.

Table 2.

Classification of Lateral Ankle Ligament Injury and Treatment Recommendations¹⁵⁾

Classification	Criteria	Recommendation
Type I	Stable ankle to clinical testing (with anesthesia, if necessary)	Symptomatic treatment
Type II	Unstable ankle with positive anterior drawer test or positive talar tilt test or both
Group 1	Nonathlete or older patient	Functional treatment
Group 2	Athlete or high-demand patient
Type A	Negative radiographic stress test	Functional treatment
Type B	Positive radiographic stress test (talar tilt angle >15。, anterior talar translation >10 mm)	Surgical repair
Type C	Subtalar instability (+)	Functional treatment

Data from the book of Coughlin and Mann (Surgery of the foot and ankle. 7th ed. St. Louis: Mosby; 1999).¹⁵⁾

Table 3.

Functional Rehabilitation Program after Acute Lateral Ankle Sprain

Goal	Suggested exercises	Frequency and duration
Restoration of motion
Active ROM exercise	Circle exercise or alphabet exercise	10 times at a time
Passive ROM exercise	Stretching using band or towel (refer to Fig. 1) Stationary bicycle	Repetition (5 times a day)
Strengthening exercise
Isometric exercise	Push against a wall or fixed object (refer to Fig. 2)	Maintenance for 10 seconds
Isotonic exercise	Resistive exercise using band (refer to Fig. 3)	10 times at a time
Plantarflexion		Repetition (5 times a day)
Dorsiflexion
Inversion
Eversion	Peroneal strengthening exercise
Proprioceptive training	Balance exercise on wobble or tilt board	5 times at a time
	One-leg standing with eyes open	Repetition (3 times a day)
	One-leg standing with eyes closed (refer to Fig. 4)
	Progress from static to dynamic balance
Walking & jogging	Gait training with straight plane	Distance gradually increase
	Zigzag walking
	Forward and backward jogging
Running	Figure-8-running	Distance gradually increase
	Cutting & jumping

Running Figure-8-running Distance gradually increase Cutting & jumping

Table 4.

Clinical Outcomes after Surgical Treatment for Acute Lateral Ankle Ligament Injury

Study	Journal	Key result
Povacz et al. (1998)⁴⁷⁾	J Bone Joint Surg Am	Nonoperative treatment of an injury of the fibular collateral ligaments of the ankle yields results that are comparable with those of operative repair and is associated with a shorter period of recovery.
Pijnenburg et al. (2000)⁴⁶⁾	J Bone Joint Surg Am	Operative treatment for ruptures of the lateral ankle ligaments leads to better results than functional treatment, and functional treatment leads to better results than cast immobilization for six weeks.
Specchiulli and Cofano (2001)⁴⁰⁾	Orthopedics	No significant differences were found between the primary repair and conservative management groups with regard to objective or subjective stability, functional scores, or the overall result.
Pijnenburg et al. (2003)⁴⁵⁾	J Bone Joint Surg Br	Compared with functional treatment, operative treatment gives a better long-term outcome in terms of residual pain, recurrent sprains and stability.
Pihlajamäki et al. (2010)⁴⁴⁾	J Bone Joint Surg Am	The long-term results of surgical treatment of acute lateral ligament rupture of the ankle correspond with those of functional treatment. Although surgery appeared to decrease the prevalence of reinjury of the lateral ligaments, there may be an increased risk for the subsequent development of osteoarthritis.
Takao et al. (2012)⁴⁸⁾	Am J Sports Med	Functional treatment alone and functional treatment after primary surgical repair showed similar overall results after acute lateral ankle sprain. But, functional treatment alone had an approximately 10% failure rate and a slower return to full athletic activity.
White et al. (2016)⁴⁹⁾	Knee Surg Sports Traumatol Arthrosc	Acute repair of grade III injuries in professional high-demand athlete leads to a predictable return to sport (approximately 10 weeks) and may reduce the incidence of repeat sprains and intra-articular damage.

Table 5.

Recent Systemic Reviews regarding the Conservative and Surgical Treatments for Acute Lateral Ankle Sprain

Study	Conclusion
Kerkhoffs et al. (2007)³⁾	There are insufficient high-quality randomized controlled trials available to give a final judgement on the effectiveness of surgery compared with conservative treatment.
Chan et al. (2011)¹⁶⁾	Given that the results of secondary repair are similar to primary repair and that functional treatment has yielded similar outcomes, surgery is rarely indicated in the acute setting.
Kerkhoffs et al. (2012)²³⁾	There was some limited evidence for longer recovery times, and higher incidences of ankle stiffness, impaired ankle mobility and complications after surgical treatment. Functional treatment is preferred over surgical therapy.
van den Bekerom et al. (2013)⁴⁾	Successful treatment of grade II and III acute lateral ankle ligament injuries can be achieved with individualized aggressive, nonoperative measures. Acute repair of the lateral ankle ligaments in grade III injuries in professional athletes may give better results.
Petersen et al. (2013)²²⁾	The majority of grades I, II, and III lateral ankle ligament ruptures can be managed without surgery. The indication for surgical repair should be always made on an individual basis.
Chaudhry et al. (2015)⁵⁰⁾	Cochrane review failed to demonstrate a benefit of surgery compared with conservative management for acute lateral ligament complex injuries. Surgery for acute lateral ligament complex injuries is not recommended, regardless of severity.
Al-Mohrej and Al-Kenani (2016)²⁴⁾	Regardless of severity, surgery for acute ankle sprain is not recommended anymore.

TOOLS

Similar articles